ARTICLE IN PRESS doi:10.1510/icvts.2007.173435
Interactive CardioVascular and Thoracic Surgery 7 (2008) 513–514 www.icvts.org
Case report - Valves
Candida parapsilosis tricuspid native valve endocarditis: 3-year follow-up after surgical treatment Ahmet Umit Gullu*, Murat Akcar, Ahmet Arnaz, Mehmet Kizilay Siyami Ersek Thoracic and Cardiovascular Surgery Center, Mutevelli Heyet Cad., Murat Sitesi. S Blok., D:13 34662 KosuyoluyIstanbul, Turkey Received 14 December 2007; received in revised form 22 January 2008; accepted 28 January 2008
Abstract In non-addicted patients, several states such as alcoholism, previous valvular heart disease or prosthetic valve replacement, immunodeficiency states, prolonged intravenous hyperalimentation, permanent pacemakers, and some congenital heart diseases can provide the predisposing factors for tricuspid valve endocarditis. It is an extremely rare occurrence in patients with normal native cardiac valves. In this report, we present a case of a 67-year-old woman with tricuspid native valve endocarditis related to Candida parapsilosis which is a very rare cause of infective endocarditis and carries a high mortality risk. An operation was indicated for the patient due to persistent enlarging vegetation on tricuspid valve, severe tricuspid regurgitation, septic pulmonary emboli and finally uncompensated respiratory and heart failure. She underwent tricuspid valve replacement with bioprothesis three years ago and now she is in a satisfactory condition without any medical treatment. 䊚 2008 Published by European Association for Cardio-Thoracic Surgery. All rights reserved. Keywords: Tricuspid valve infection; Fungal endocarditis; Candida parapsilosis
1. Case report A 67-year-old woman was admitted to our hospital with dyspnea and fatigue. She had undergone left wrist surgery due to carpal tunnel syndrome two months ago. There was no history of cardiac disease, diabetes mellitus, hypertension or drug abuse. On admission, her temperature was 37.1 8C, pulse 86 beatsymin and her blood pressure was 124y76 mmHg. Cardiac examination revealed a grade IIIyVI pansystolic murmur at the 4th left parasternal border. The results of laboratory studies revealed an erythrocyte sedimentation rate of 108 mmyh, a white blood cell count of 9080 cellsymm3, hematocrit level 28.9%, D-Dimer 884 ngyml, C-reactive protein 8.6 mgydl, and otherwise normal. Transthoracic and transesophageal echocardiography demonstrated 13=10 mm mobile vegetation on the anterior and posterior leaflets of the tricuspid valve with severe regurgitation. Three blood cultures had been taken irrespective of body temperature 1 h apart at the first day of admission. During the evaluation of the reason for dyspnea, she underwent spiral computed tomography (CT) scanning and lung ventilation perfusion scintigraphy (3mCi Tc 99mMMA) which both demonstrated subsegmenter perfusion defects at the anterobasal and laterobasal segments of the left lung. All these findings led to the diagnosis of pulmonary thromboemboli. On the fourth day after admission her blood culture was positive for Candida parapsylosis and meanwhile, susceptibility testing showed the isolate to *Corresponding author. Tel.: q90 505 5013844; fax: q90 216 3379719. E-mail address:
[email protected] (A.U. Gullu). 䊚 2008 Published by European Association for Cardio-Thoracic Surgery
be susceptible to amphotericin B and fluconazole which was evaluated by the microdilution method. Subsequently, amphotericin B (0.6 mgykgyday) and fluconazole (6 mgykgyday) therapy was initiated. A second control transthoracic echocardiography demonstrated 23=12 mm mobile vegetation on the tricuspid valve which was still enlarging despite three days of anti-fungal therapy. She had tachypnea, tachycardia with worsening arterial blood gas parameters. A surgical intervention was indicated for the patient the day after her second control transthoracic echo-cardiography due to persistent enlarging vegetation on the tricuspid valve, severe tricuspid regurgitation, septic fungal pulmonary emboli and, finally, uncompensated respiratory and heart failure. At the operation the fragile vegetation was attached to the anterior and posterior septal leaflets (Fig. 1). The tricuspid valve was resected and valve replacement performed with bioprosthesis (29 mm, St. Jude, Biocor䊛, Medical Inc., USA) by pledgeted non-everting mattress suture technique. C. parapsilosis was isolated from culture of the excised valve and histopathology revealed numerous budding organisms. The patient was treated with intravenous amphotericin B and fluconazole for 30 days and discharged under oral flucanozole therapy for six months. She had oral anticoagulation therapy with warfarin for just two months after the operation but continued to take asprin. Annually repeated transthoracic echocardiography demonstrated a normally functioning prosthetic tricuspid valve without vegetations and also a series of blood cultures were negative at six months and one year after completion of therapy. After surgical and
ARTICLE IN PRESS A.U. Gullu et al. / Interactive CardioVascular and Thoracic Surgery 7 (2008) 513–514
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Fig. 1. The view of the vegetation on the native tricuspid valve.
medical therapy, the patient remains clinically well and free from recurrent endocarditis without any medical treatment at three years follow-up. 2. Discussion Fungal endocarditis is an uncommon disease and, even accounting for only 1.3–6% of all cases of infectious endocarditis, it carries a high mortality risk. Although C. albicans represents the main etiology of fungal endocarditis, C. parapsilosis is the most common non-albicans species w1x. Right-sided infective endocarditis is a frequent complication among intravenous drug abusers but in non-addicted patients, several states such as alcoholism, immunodeficiency states, prolonged intravenous hyperalimentation, permanent pacemakers, and some congenital heart diseases can provide the predisposing factors for tricuspid valve endocarditis. It is an extremely rare occurrence in patients with normal native cardiac valves. In our case the predisposing factor seems to have been previous surgical intervention for carpal tunnel syndrome or using broad-sprectral antibiotics in that period. In the reports of Galgiani and Girmenia, one of the sources of infection was the tears in surgical gloves worn by carrier surgeons w2, 3x. But unfortunately the real reason of infection in the present study is not clear. C. parapsilosis strains associated with invasive disease are more likely to produce biofilm structures that are morphologically different from those produced by C. albicans w4x. Therefore, C. parapsilosis induced endocarditis is difficult to treat completely and particularly it is a slow-growing infection which has been reported to recur as late as 43 months after a positive blood culture w5x. There are many cases of recurrence and death after treatment for fungal endocarditis w6x. In the recent study of Musci et al. with their 20 years of experience, they found a highly significant decreased survival rate of
patients who were operated on due to isolated right-sided and those who had to be operated on due to combined right- and left-sided: the 30-day, 1-, 5-, 10- and 20-year survival rate after isolated right-sided operation was 96.2%, 88.4%, 73.5%, 70.4% and 57.7%, respectively, in comparison to 72.0%, 67.8%, 50.8%, 35.6% and 35.6% after an operation for combined right- and left-sided endocarditis w7x. But in this study the majority of the patients had bacterial endocarditis, so we think that survival of fungal endocarditis is probably worse. Even the ideal treatment strategy for Candida endocarditis has not been formally tested in prospective randomized controlled studies; in the review of cases documented in the literature it shows that combined surgical and medical therapy is associated with a lower mortality rate w1, 8, 9x. In the guidelines of the American College of Cardiology (ACC) and the American Heart Association (AHA) they stipulate surgical indications for fungal endocarditis (Class I recommendation). Moreover, the recent Infectious Diseases Society of America (IDSA) guidelines on Candida endocarditis recommend that it should be treated by valve replacement, either for native or prosthetic valves w10x. In fact, in our patient, valve replacement was unavoidable due to widespread infection of the native valve. It is still controversial which prosthesis is the best option; we generally prefer biological valves in tricuspid position. As a conclusion, right-sided endocarditis is one of the most serious manifestations of the candidiasis. However, with aggressive medical and surgical therapies the patients may have long-term favorable outcomes even when they need valve replacement because of destruction of the native valve and widespread infection. References w1x Garzoni C, Nobre VA, Garbino J. Candida parapsilosis endocarditis: a comparative review of the literature. Eur J Clin Microbiol Infect Dis 2007;26:915–926. w2x Galgiani JN, Stevens DA. Fungal endocarditis: need for guidelines in evaluating therapy. Experience with two patients previously reported. J Thorac Cardiovasc Surg 1977;73:293–296. w3x Girmenia C, Martino P, De Bernardis F, Gentile G, Boccanera M, Monaco M, Antonucci G, Cassone A. Rising incidence of Candida parapsilosis fungemia in patients with hematologic malignancies: clinical aspects, predisposing factors, and differential pathogenicity of the causative strains. Clin Infect Dis 1996;23:506–514. w4x Shin JH, Kee SJ, Shin MG, Kim SH, Shin DH, Lee SK, Suh SP, Ryang DW. Biofilm production by isolates of Candida species recovered from nonneutropenic patients: comparison of bloodstream isolates with isolates from other sources. J Clin Microbiol 2002;40:1244–1248. w5x Tonomo K, Tsujino T, Fujioko Y. Candida parapsilosis endocarditis that emerged 2 years after abdominal surgery. Heart Vessels 2004;19:149– 152. w6x Rubinstein E, Lang R. Fungal endocarditis. Eur Heart J 1995;16:84–89. w7x Musci M, Siniawski H, Pasic M, Grauhan O, Weng Y, Meyer R, Yankah C, Hetzer R. Surgical treatment of right-sided active infective endocarditis with or without involvement of the left heart: 20-year single center experience. Eur J Cardiothorac Surg 2007;32:118–125. w8x Kan C-D, Luo CY, Lin PY, Yang Y-J. Native-valve endocarditis due to Candida parapsilosis. Interact CardioVas Thorac Surg 2002;1:66–68. w9x Steinbach WJ, Perfect JR, Cabell CH, Fowler VG, Corey GR, Li JS, Zaas AK, Benjamin DK Jr. A meta analysis of medical versus surgical therapy for Candida endocarditis. J Infect 2005;51:230–247. w10x Pappas PG, Rex JH, Sobel JD, Filler SG, Dismukes WE, Walsh TJ, Edwards JE. Guidelines for treatment of candidiasis. Clin Infect Dis 2004;38:161–189.
